title: Endovascular aortic aneurysm repair in patients with hostile neck anatomy.
abstract: OBJECTIVE
  To report a systematic review and meta-analysis of outcomes following endovascular aneurysm repair (EVAR) in patients with hostile neck anatomy (HNA) vs. those with favorable neck anatomy (FNA).
  
  
  METHODS
  Systematic review and meta-analysis of data on EVAR in patients with HNA and FNA was performed by 2 reviewers in February 2013. An eligible study was required to have at least 50 participants and to incorporate one or more of the HNA criteria of neck length <15 mm, neck diameter >28 mm, and/or angulation >60°. Of the 24 full-length articles ultimately reviewed, 8 were excluded, resulting in 16 articles that were suitable for inclusion in the meta-analysis. The study size ranged from 55 to 5183 participants, with a total of 8920 patients in the FNA group and 3039 patients in the HNA group. Mean follow-up ranged from 9 to 49 months.
  
  
  RESULTS
  Analysis of the pooled data revealed a significant increase in 30-day mortality (2.4% FNA vs. 3.5% HNA; OR 1.60, 95% CI 1.13 to 2.27; p<0.01), intraoperative adjuncts (8.8% FNA vs. 15.4% HNA; OR 1.88, 95% CI 1.15 to 3.07; p=0.01), and 30-day migration (0.9% FNA vs. 1.6% HNA; OR 2.08, 95% CI 1.20 to 3.62; p=0.009) in patients with HNA. A decrease in primary technical success (97.5% FNA vs. 93.8% HNA; OR 0.41, 95% CI 0.18 to 0.93; p=0.03) was significant when all 3 criteria were used to define HNA. For outcomes at >30 days, the increase in secondary interventions (OR 1.29, 95% CI 1.00 to 1.66; p=0.05) approached significance, but aneurysm-related mortality, all-cause mortality, migration, and aortic rupture did not achieve statistical significance. There was no difference in rates of sac expansion. Analysis of endoleak rates revealed a significant increase in 30-day type I endoleaks (OR 2.92, 95% CI 1.61 to 5.30; p<0.001) and late type I endoleaks (OR 1.71, 95% CI 1.31 to 2.23; p<0.0001) in patients with HNA.
  
  
  CONCLUSIONS
  These results suggest that performing EVAR in patients with HNA increases the technical difficulty and results in poorer short-term outcomes. The higher rates of early and late type I endoleaks, along with secondary interventions, suggest that increased monitoring should be performed in this category of patient to ensure rapid treatment.
authors.affiliation: Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, UK.
authors.forename: Philip W
authors.initials: PW
authors.lastname: Stather
authors.forename: John B
authors.initials: JB
authors.lastname: Wild
authors.forename: Robert D
authors.initials: RD
authors.lastname: Sayers
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bown
authors.forename: Edward
authors.initials: E
authors.lastname: Choke
mesh_terms: D001011:Aorta / Q000473:pathology / Q000601:surgery*; D001014:Aortic Aneurysm / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016009:Chi-Square Distribution; D057867:Endoleak / Q000209:etiology / Q000401:mortality / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D016017:Odds Ratio; D018579:Patient Selection; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome